GW1-2021-07902_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) 4� For Internal Use Only: Prinf rm:
1.Well Contractor Information: l op l lz'l
0 r h(4A Its N�0-0 k5 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name / r
�l ft I,-
t 10Ui'� ^?s rLq L i.�" !
ft. •9_ft. to V,vi ,
NC Well Contractor Certification Number 15.OUTER CASING(formulti-cased wells)OR LINER 0f a livable
James Darby Well Drilling LLC FROM TO DIAMETER TEHCKNESS MATER-
Company Name .0 ft. ' ft to IN 1- J�a
21-343 16.INNER CASING OR TUBING(geothermal closed400
` 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
I Agricultural [3Municipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) xj Residential Water Supply(single) fa ft. in.
i Industrial/Commercial 31tesidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o
It fa
Monitoring _i Recovery ft. fL
Injection Well: IL ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OJ Stormwater Drainage fa ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUrock e,gmin size,etc.
ni Geothermal(Heating/Cooling Return) J Other(explain under#21 Remarks) ft
4.Date Well(s)Completed: r Well ID# ft ff �t3t1
5a.Well Location: R 15-8 ft.4
Shelia Caulder 'S ". 6 T ns'-vt w&'1AJ R-c-le--
Facility/Owner Name Facility ID#(if applicable) Lj ft. 'q c frL
6010 Pleasant Grove Rd, Waxhaw NC 28173 '
Physical Address,City,and Zip fA ft
Union 21.REMARKS ^I
County Parcel Identification No.(PIN) Iv
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)o1x Permanent or OTemporary SighaSre of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or X)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC Z7699-1636
13a.Yield(gpm) Method of test-blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 7 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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